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So you’ve landed the long awaited internship opportunity. No more showing up at potential sites with yet another fine linen resume, ink barely dry, hoping that the clinician you seek isn’t behind with their case notes for that particular day nor finds your beard particularly disturbing. You discovered that diamond in the rough, a chance to begin the final chapter of likely your largest financial investment to date. What now?

Here are a few points to guide you toward the successful completion of your clinical internship, the culminating experience of your mental health degree.

Establishing a plan. While you will be told this, probably understand its necessity and are likely doing so as a requirement, you should really take the time to thoughtfully plan. Ideally your plan for your clinical experience is done through conversation with your supervisor. Items such as schedule availability for client contact as well as individual and group supervision is a must, but also include how supervision will transpire (e.g. video recording, in-person, verbatim, etc.). One plausible sticking point may be satisfying the CACREP criteria for “some” experience in leading groups. Discuss this note specifically with your supervisor.

Do the math. How many hours do you need per week to complete your program in your desired (or required) timeline? Don’t forget to plan for academic breaks, vacations and other schedule conflicts.

Consider the caseload of the site. Ask your supervisor if it is feasible to maintain a steady caseload throughout the year. Many practices see a decrease in clientele during particular times of year. Don’t believe the minimum is enough, plan for being sick, fluctuating caseloads, no shows and cancellations. Contemplate the impact of time requirements for endeavors such as school or home visits and coordinating care.

And remember, while you can likely continue to accumulate hours during breaks within the semester, you will most likely not be able to accumulate hours between semesters. These weeks add up. In the end, it’s more advantageous to have too many hours than not enough. The more hours the more experience you have moving forward. Not enough hours likely results in another academic semester!

Setting goals. Goals related to competence not simply having the goal of completing the requisite hours. Having goals related directly to completing your degree and to becoming a better counselor are necessary to get the most out of this phase of your journey. For example, if you plan to get licensed, you will have to pass a state exam. Have a resource such as the Encyclopedia of Counseling handy. Have access to resources related to your theory of choice and research interventions which may relate to your current caseload.

At this stage, you may benefit from reviewing case notes or assessments and relating themes, symptoms, and processes with the material you have learned and are learning in school. Put your goals on paper, ask for feedback and if your school doesn’t provide a form, find a way to track your progress. Through discussion, compare your self-evaluation with your supervisor’s observations.

Calculating hours. Understand how your hours should be counted. This should meet your academic requirements and also the educational requirements for the state you wish to eventually seek licensure. This includes distinguishing what, if any, of your academic class time counts as supervision. Additionally, understand that your administrative proficiency will likely increase over the course of your clinical training experience. Items such as post-session notes and case management will take up a great deal of your time early on, this may mean less time for client-contact. However, be abreast of lulls that may occur as your administrative proficiency increases and work with your supervisor to adjust your caseload accordingly.

Understand co-therapy is not merely sitting in observing your supervisor conduct a session. Get clarity from both your state board and your academic institution regarding distinguishing time being observed, doing observation and engaging in co-therapy. Calculating your hours is dependent upon your role in the session, not necessarily how you refer to the experience. I’m sure you know the importance of keeping record of your time, but I’d be remiss not to mention it. Minding confidentiality, make your records inclusive. This is not only a requirement, if done particularly can provide you with valuable qualitative and quantitative information for job seeking purposes later on.

Remembering the hierarchy. Yes, you’re thinking about Maslow which is great, but here I am reminding you the client always comes first. Early on you may find yourself sitting in during sessions. Clients’ permission must be obtained prior to sitting in during a counseling session whether or not co-therapy is being performed. If a client declines to permit you into a session, don’t take it personally. There are too many possible reasons for such a decision by a client and the overwhelming majority of those possible reasons likely have little to do with you personally. The client’s needs are above both site and school requirements.

This can be a complex concept or a non-issue, but should remain central to the therapeutic process. A common reason clients prefer not to introduce you into the session, especially early in the internship, is because they have established rapport with their counselor and are simply comfortable working with that person in the established manner. As new clients arrive at the site, it becomes easier to integrate you into the process.

Minding your own mental health. Don’t forget your own mental health. Counselors in training may be on the extremes concerning time. Some interns may not have much else going on other than their internship while others are working several jobs and have others who are dependent on them. In either case, beware of countertransference. If your emotions are high and/or out of control you may run a risk of losing track of the therapeutic process. While in itself countertransference is not necessarily a fault, ignorance of its presence can be harmful to the client as well as result in ethical dilemma. If at any time you feel concerned about your feelings toward or relating to a client a discussion with your supervisor should be in order. Establishing good routines which include eating appropriately, drinking water, sleeping, and exercising are important. Also, schedule some “me time” in between your school work, clinical work, and other obligations.

Assuring confidentiality and ethical standards. Client’s names are never presented to individuals at your academic institution; initials are acceptable. Concerning client information, a good rule of thumb is maintaining a double lock standard. This relates to traveling to and from the site, storage at home, laptops, audio/video recording devices, etc. Client paperwork and digital information should be protected and stored until the statute of limitations on malpractice expires or you graduate, whichever occurs last. In general, when there are competing guidelines always defer to the higher standard. Remember, guidelines are set by your academic institution, the internship site, state law, associations Codes of Ethics, etc. You won’t be the first to find it confusing at times.

Furthermore, understand ethics codes generally act as guidelines. They may lack clarity, conflict with laws, be reactive versus proactive, etc. Being ethically responsible as a counselor is not necessarily complicated but it takes being educated and appropriately mentored to hone in on best practice. Some points to remember include the importance of informed consent. Specifically state your status as a graduate intern, your requirement to be supervised and note how your work with them may be integrated into your scholastic endeavor. Of course, always get permission (often by way of a Release Form either from your site or academic institution) from clients prior to any type of recording of session content. For individuals under 18, it is best practice to have both the client and their legal guardian grant written permission.

You may have heard it before, but don’t forget it:

Don’t be on time, be early.

Maintain liability insurance. You may have to renew this during the course of your training.

Dress appropriately and maintain acceptable grooming standards.

Expect to be introduced as an intern. Prepare for this. It may prove more difficult to deal with than you think.

Caring confrontation. Yes, with your clients but also with your supervisor. For example, find ways to improve the environment or administrative processes and make suggestions. As well, it has likely been some time since your supervisor completed her degree. Offer discussions based on things you are learning in your academic setting. Be an asset! You’ll likely be looking for a job and/or supervision after graduation to suffice your state requirements. Your current site could offer to keep you on if you’re valuable or at the least offer you a solid reference letter.

Concentrate on what you do well, as well as things you don’t. Use this supervised experience to face what you feel is most challenging and leverage your current skill set to overcome your fears. Work with silence, work with children, work with the opposite gender, etc. Do it while you have help readily available.

I can stare in the mirror and recite, “Every day, in every way, I’m getting better and better,” and I will still experience my life as awful unless I also have opportunities to succeed or I live in a community where, by comparison, I am no worse off than others. Wellbeing is a social phenomenon (Ungar, 2014).

It is no secret that poverty and unemployment are highly correlated; however, it is somewhat less widely known that these factors mediate, and are influenced by, mental health. Recent research suggests that socio-economic hardship precedes inferior mental health (Heflin & Iceland, 2009). Commonly, mental health is associated with emotions and feelings including stress, depression and loneliness. On the other hand, mental illness is reserved by many for diseases and disorders such as schizophrenia, bipolar disorder, posttraumatic stress disorder, etc. The reality is that many diagnosable mental disorders are based on criteria regarding the factors considered by many to be a part of everyday life (i.e. stress, anxiety, alcohol, drug and even tobacco use). The Mayo Clinic estimates that one in five adults experience mental illness in a given year (2015). Furthermore, Kessler states that forty-six percent of Americans experience at least one mental disorder in their lifetime (as cited in Anakwenze & Zuberi, 2013, p.147). In either course, the mental state of an individual, and societies at large, have vast socioeconomic implications. Scholarly contributions from the United Kingdom suggest that the lowest wage-earners are twice more likely to experience mental health issues than average wage-earners and are more likely to experience unemployment (Kronenberg, Jacobs & Zucchelli, 2015). In 1997, William Julius Wilson found a relationship between poverty and mental health, of which, he concluded that unstable work and low income decrease self-efficacy (as cited in Anakwenze & Zuberi, 2013, p. 148). However, despite a rather lengthy history of research concerning the topic (which continues to be empirically vetted), there has yet to emerge a viable socio-economic prescription for mental illness. This review of literature focuses on determining the key socioeconomic factors associated with mental illness, and adds clarity to the relationship between poverty, unemployment and mental health.

Finding a place in society

As a part of the Fair Labor Standards Act in the U.S., the Wage and Hour Division of the Department of Labor [DOL] authorizes employers to pay subminimum wages to individuals who possess disabilities that effect job performance (2008). Mental illness is included among the list of impairments which qualify for a subminimum wage (DOL, 2008). Regardless of the intent, these standards imply a degradation of value to those with mental illness. The chasm between economical and humanistic thinking is evidenced by such government actions. That is, economically, individuals lose their name and their very identity (i.e. self-efficacy) and are considered in conventional terms, “factors of production”, “government expenses”, “buyers and sellers”, to name a few. Government intervention that provides a means for employers to pay individuals with mental illness less for jobs which they are less than qualified, does little to fix any economic or mental health dilemma. Efforts may better be served by providing resources, such as research endeavors purposed with determining suitable employment options for those with specific mental illness. Employing individuals in positions where their efforts and productivity are economically valuable to employers decreases the need for subminimum wage authorizations, and has potential to improve workers’ mental health and the business’ output. One challenge to this effort may be that individuals with serious psychological distress are more likely to have less than a high school diploma (Heflin & Iceland, 2009).

Not only do mentally disabled individuals face difficulty fitting into the workforce, they also are more likely to face sub-quality living conditions. In the United Kingdom, one in three households, housing a disabled person is considered to be substandard (Snell, Bevan & Thomson, 2015). These substandard conditions not only create a sense of dissatisfaction for those residing in such dwellings but also increase their susceptibility to chronic illness (Snell et al., 2015). These individuals’ increased susceptibility to illness is, in part, due to rising energy prices and the inability to afford heat and/or air conditioning (Snell et al., 2015). Because many of these individuals lack employment, it is assessed that more time is spent in the home, thus exacerbating the amount of time they are exposed to substandard conditions (Snell et al., 2015). Heflin & Iceland (2009) concluded that providing relief for energy costs and eviction prevention may have high social benefits, especially if provisions are extended to those within two hundred percent of the poverty line, as oppose to only those living in poverty.

The individual’s perception of their condition and the associated dissatisfaction both play a role in increasing the individual’s risk of experiencing depression (a degraded or impaired mental state) (Anakwenze & Zuberi, 2013). Depression can aggravate an existing mental health condition or in itself become a mental illness. The living conditions available to those with disabilities, including mental illness, is largely impacted by their ability to find and sustain employment providing the necessary income for suitable accommodations. The condition they find themselves in (i.e. facing mental illness, unemployment and poverty) is a cyclically diminishing one. It doesn’t take a John Maynard Keynes to understand that this cycle cannot recover itself efficiently.

Affording treatment

Well into the U.S.’s 2015 political debate season, a potential increase in minimum wage remains a pivotal topic. Many Americans are in favor of increasing the minimum wage standards, suggesting a societal need for increased income. To be clear, mentally healthy individuals making minimum wage claim to need more money. How can poor, mentally ill individuals, earning a subminimum wage afford treatment? The reality is that they likely cannot. But even if provided with income increases, mental health can only be improved by monetary gains if those gains are employed appropriately by the individual.

It has been suggested that an increase in minimum wage would improve mental health. This is largely based on research which has found positive correlations between income and mental health. Kronenberg et al. (2015) points out the expenses businesses can attribute to mental illness, such as absenteeism, and suggests that a minimum wage increase could improve mental health and productivity, thus becoming an affordable expense. While this logic may hold some merit, it is not determined if individuals would invest additional income towards improving their mental health and, moreover, there is a lack of empirical evidence to support such assumptions. It is determined, however, that disabled individuals, as compared to non-disabled individuals, face proportionally greater increasing living costs, are less likely to be employed, are less likely to be employed full-time (if employed), and receive lower wages (Snell et al., 2015).

In many instances, individual’s mental disorders go untreated. While this in itself is tragic and sometimes fatal, in impoverished communities it is more likely that a mentally ill parent’s interactions with their children be harmful. Not only do children in these situations grow up with the same economic insecurities, they are exposed to, and are affected by, the stress, anxiety, and depression present within the household. These situations have a biological effect on the brain and require treatment (Anakwenze & Zuberi, 2013). This needed treatment often doesn’t occur. In many cases, mental illness coupled with poverty leads to criminal activity and imprisonment. Harding suggests that a physiological mechanism exists by which the violence present within low income neighborhoods yields mental health concerns, such as chronic stress (as cited in Anakwenze & Zuberi, 2013, p. 150). These mental health problems undermine individual’s self-efficacy and perpetuate further negative consequences.

The socioeconomic issues covered herein do little to scratch the surface of what seems to be a nearly silent epidemic. Overshadowed by international threats, presidential debates and Hollywood shenanigans, the issue of mental illness has many socioeconomic implications. I suggest further research is needed in many areas related to mental health reform, to include: the role of mental illness concerning violent and juvenile offenders, neighborhood disorder (i.e. perceived levels of social support and integration), and the relationships between depression, aggression, addiction and trauma. The relationship between poverty, unemployment and mental health is complex, yet it can be reduced to a simple term, vicious circle. I conclude that mental health care in the U.S. is a substantial component to economic stability. Reformation of the economic strategy should include progressive government intervention in impoverished communities, to include crime prevention, education, job training and mental health rehabilitation and sustainment. Such programs create a demand for jobs and supply qualified job seekers. Long-term, such programs reduce crime rates and unemployment as well as have the potential to increase gross domestic product.